10 Choosing Wisely Recommendations by Specialists for Hospitalists

Many respiratory problems, such as bronchiolitis, asthma, and even some pneumonias are caused or exacerbated by viruses, points out Ricardo Quiñonez, MD, FAAP, FHM, section head of pediatric hospital medicine at the Children’s Hospital of San Antonio and the Baylor College of Medicine, and chair of the AAP’s section on hospital medicine. In particular, there are national guidelines for bronchiolitis and asthma that recommend against the use of systemic antibiotics.

This recommendation may be difficult for hospitalists to implement, because antibiotics are frequently started by other providers (PCP or ED), Dr. O’Callaghan admits. It can be tricky to change or stop therapy without undermining patients’ or parents’ confidence in their medical decision-making. Hospitalists may need to collaborate with new partners, such as community-wide antibiotic reduction campaigns, in order to affect this culture change.

“Echocardiography can diagnose all types of heart disease while being completely safe, inexpensive, and available at the bedside. These features may logically lead hospitalists to think, ‘Why not?’ Maybe there’s something going on and an echo can’t hurt. Unfortunately, tests can have false positive findings that lead to other, potentially more hazardous and invasive, tests downstream, as well as unnecessary delays.”

—James D. Thomas, MD, FASE, FACC, FAHA, FESC, Moore Chair of Cardiovascular Imaging at the Cleveland Clinic in Ohio and past president of the American Society of Echocardiography.

10 American College of Obstetricians and Gynecologists (ACOB)

Recommendation: Don’t schedule elective inductions prior to 39 weeks, and don’t schedule elective inductions of labor after 39 weeks without a favorable cervix.

Studies show an increased risk to newborns that are electively inducted between 37 and 39 weeks. Complications include increased admission to the neonatal intensive care unit, increased risk of respiratory distress and need for respiratory support, and increased incidence of infection and sepsis.

This recommendation may be difficult for hospitalists to implement, because obstetrical providers typically schedule elective inductions. Implementation of this recommendation would involve collaboration with obstetrical providers, with possible support from maternal-fetal and neonatal providers.

“Recent quality measures and initiatives from such organizations such as CMS and the National Quality Forum … may help to galvanize institutional support for its successful implementation,” says Dr. O’Callaghan, a Team Hospitalist member.

Elective surgeries should only be done in cases where there is a medical necessity, such as when the mother is diabetic or has hypertension, adds Rob Olson, MD, FACOG, an OB/GYN hospitalist for PeaceHealth at St. Joseph Medical Center in Bellingham, Wash. “Hospitalists should not give in to pressures from patients who are either tired of the discomforts of pregnancy or have family pressure to end the pregnancy early.”

Karen Appold is a freelance writer in Pennsylvania.

References

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